PLAINTIFF'S STATEMENT A Plaintiff's Statement is to be filed with a Statement of Claim for Small claims actions and/or a Complaint for Eviction. The name, address and phone number have to be completed in order for the Clerk's office to fully assist you in the preparation of your claim. The amount of the claim is what you are seeking in any damages. In evictions, your claim would include back rent, damages, etc. until the date of filing. Date when alleged debt is when the debt occurred or for the time periods of when the rent was due. Place of alleged debt or contract is where the debt occurred or if an eviction is filed, the address of the premises you want possession of. You also need to know if the defendant is currently in the military or not. INSTRUCTIONS FOR Contact the Civil Law Department at (904) 284/269-6363 if you have any questions regarding completing this form. 2002 © American LegalNet, Inc. IN THE COUNTY COURT, CLAY COUNTY, FLORIDA ACCURATE COMPLETION OF THIS STATEMENT IS NECESSARY SO THAT THE CLERK CAN ASSIST YOU IN THE PREPARATION OF YOUR CLAIM PLAINTIFF'S STATEMENT: PLEASE PRINT Name of Plaintiff Address of Plaintiff Amount of Claim $ This claim is for: (Check the box that applies to your claim) ( ( ( ( ( ( ( ( ) ) ) ) ) ) ) ) Goods, ware, and merchandise sold by plaintiff to defendant; Work done and materials furnished by plaintiff to defendant; Money loaned by plaintiff to defendant; Money due to plaintiff upon accounts stated and agreed to between them; On a written instrument, copy of which is attached hereto; Rent for certain premises in Clay County, Florida, viz: Other (Explain) Any additional facts in connection with any of the above: (use back of sheet if necessary) Telephone No. Date when alleged debt or contract was incurred or damages occurred Place where alleged debt or contract was incurred or damage occurred If the defendant is an individual, is he/she in the military service? swear under oath to the fact? NOTE: If not, are you prepared at this time to (A) If you are suing an individual, give him/her full name. (B) If you are suing a business firm, give the firm name and the name of the owner. (C) If you are suing a partnership, you must NAME ALL of the partners. (D) If you are suing a corporation, give its full name, state where incorporated, and names and addresses of its officers (President, Vice President, Secretary, Treasurer) (E) If your suit arises as a result of an automobile accident, you may name the drive, and also the registered owner of the vehicle. (F) If you are unable to determine which of the above applies to your case, please see the Clerk. My claim is against (Name and address of defendant(s) Plaintiff of Agent 2002 © American LegalNet, Inc.